Acta Scientific Dental Sciences (ISSN: 2581-4893)

Volume 2 Issue 9 September 2018

Case Report

The Problem of Excess: A Case Series on Gingival Enlargement

Deshpande Abhinav*, Mala Dixit Baburaj, Pimpale Sandeep and Tambe Lashika
Department of Periodontics, Nair Hospital Dental College, Maharashtra University of Health Sciences, India
*Corresponding Author: Deshpande Abhinav, Department of Periodontics, Nair Hospital Dental College, Maharashtra University of
Health Sciences, India. E-mail: [email protected]
Received: July 30, 2018; Published: August 24, 2018

Abstract
Background: Inflammatory gingival enlargement represents an abnormal overgrowth of gingiva in response to local irritants. The
overzealous reaction to irritants manifests in inflammation and enlargement of gingiva causing functional disturbances and hinder
oral hygiene maintenance. This case series reports 3 different ways of management of inflammatory gingival enlargement.
Methods: The treatment strategy depends upon tissue changes. It involves a Non-surgical and surgical approach. Non-surgical ther-
apy involving scaling and root planing aims to remove local irritants and reverse the inflammatory changes. Splinting of mobile teeth
helps in stabilizing dentition and providing optimum conditions for healing. When there is no significant reduction of enlargement,
gingivectomy (External bevel or Internal bevel Gingivectomy) helps in restoring the gingival contours.
Results: Periodontal therapy aims to restore the health and function of the dentition. The systematic treatment approach resulted in
uneventful healing and stable results which are easily maintained by the patients.
Conclusion: As Periodontal therapy is diagnosis- driven, thorough periodontal assessment helps in development of a rational treat-
ment plan. This should include modification of risk factors which potentiates progression of plaque induced periodontal disease. The
specific therapeutic endpoint includes establishment of gingival contours amenable to cleaning and health.
Keywords: Gingival Enlargement; Gingivectomy; Scaling and Root Planing; Chronic Irritation; Hyperplasia

Introduction Case Description and Results

Case I
Gingival Enlargement (also known as Gingival hypertrophy or
Gingival Hyperplasia) is an abnormal overgrowth of gingival tis- A 35 year old female, unmarried, saleswoman by occupation
sues. It is a response by the host to various stimuli ranging from reported to department of Periodontology with a chief complaint
plaque induced, systemic, hormonal disturbances, blood dyscra- of swelling and bleeding from gums. Being a saleswoman, the pa-
sias, drug induced or genetic origin/predisposition [1]. tient was concerned with the displeasing appearance because of
the swelling. The swelling was noticed first 3 years back as small
Inflammatory gingival enlargement can be acute or chronic,
nodular enlargement in between the teeth which gradually in-
the most common form being chronic. The degree and extent of
creased to current size. As the swelling increased, the patient re-
enlargement cause increase in functional disturbances, acting as
ported redness of gums and bleeding on eating and brushing teeth.
hindrance during oral hygiene performance. This further perpetu-
Presently, the gums bleed spontaneously due to which patient has
ates the increase in plaque accumulation and the resultant chronic
stopped brushing her teeth and uses mishri for cleaning her teeth
inflammatory response [2].
as advised by her friend.
The underlying etiology and subsequent tissue changes mani-
There was no significant medical, dental, or family history. The
fested by them dictate the management strategies. The patient mo-
patient was reluctant to smile and would cover her mouth while
tivation, compliance and ability to perform adequate oral hygiene
talking or smiling. Intraoral examination revealed Grade 2 gingi-
determine the success of treatment. The treatment involves a non-
val enlargement [3]. Lips were incompetent. Maxillary left lateral
surgical phase involving Scaling and Root Planing and control of the
incisor was palatally placed. The mandibular central and lateral
etiologic factors. This result in reduction of tissue edema and infec-
incisors were grade II and grade I mobile respectively. Traumatic
tive cell infiltrate which reduces the size of enlargement. When sig-
occlusion was present. The enlarged gingiva was reddish, nodular,
nificant fibrotic component is present, it will not respond to non-
soft and edematous, bled spontaneously.
surgical therapy alone; surgical therapy is required to remove the
excess tissue [2].

Citation: Deshpande Abhinav., et al. “The Problem of Excess: A Case Series on Gingival Enlargement”. Acta Scientific Dental Sciences 2.9 (2018): 92-98.
The Problem of Excess: A Case Series on Gingival Enlargement

93

A treatment plan consisting of initial periodontal therapy fol- The intraoral examination revealed swelling on facial aspect of
lowed by gingivectomy procedure was formulated to improve 21, 22 and 42, 41, 31, 32 region. Plaque and calculus were present
aesthetics and function. The initial periodontal therapy compris- and crowding was noticed wrt 11, 21. Grade II mobile 31, 41 and
ing supragingival and subgingival scaling was performed. Occlusal Grade I mobile 32, 42. Radiographic investigations revealed hori-
adjustment was done to relieve traumatic occlusion. Oral hygiene zontal bone loss upto apical third in upper and lower anteriors.
instructions were given and the use of chlorhexidine mouthwash
(0.2% ClohexTM, Dr. Reddy’s Laboratories Ltd., India) twice a day The treatment plan included scaling and root planing and oral
for one week was advised. The patient was advised to stop appli- hygiene instructions. The patient was advised to use soft bristle
cation of mishri and use a soft bristle toothbrush with fluoridated toothbrush using Modified bass technique. The patient was re-
dentifrice using Bass brushing technique. The patient was recalled viewed every week for one month during which patient’s compli-
every week for 2 months. At this stage, radiographs were taken and ance was noted and oral hygiene instructions reinforced. Occlusal
complete blood count investigations were carried out. Splinting of adjustment was done and mandibular anterior teeth were splint-
lower anteriors was done using a fibre splint (Ribbond). ed using fiber splint (Ribbond).

After two months, the gingival enlargement did not show con- The swelling was markedly reduced 1 month following scaling
siderable reduction in size, but the tissues appeared to be pink in and root planing and was kept on maintenance phase. After 1 year
colour and firm in consistency. Surgical therapy was decided upon recall, the patient showed healthy gingiva and stable dentition and
to correct the anatomic disfigurement and render a self-cleansable displayed satisfactory oral hygiene (Figure 3).
contour to the gingiva.
Case III
Under local anaesthesia, the maxillary arch gingival enlargement
was surgically excised using Internal bevel gingivectomy incision. A 17 year old college going girl reported with complain of
Through debridement was done and flaps were closed using 3-0 swelling and bleeding of gums in upper and lower anterior teeth
mersilk sutures using interrupted suturing technique in interdental region since 1 year. She noticed slight increase in gums around a
areas. The excised tissue was sent for histopathology examination. year back. The swelling started in the interdental region as exten-
After one week, sutures were removed and oral hygiene instruc- sions of gums. It gradually progressed to involve the clinical crown
tions reinforced. and at present, covers almost the entire crown in lower teeth. No
relevant medical, dental or family history was present.
A similar procedure was done in the mandibular arch at differ-
ent scheduled appointments. After 2 weeks, the patient was re- On examining, Grade III enlargement (Bokenkamp) was noted.
viewed and healing was found to be satisfactory. The patient was Crowding of lower Pseudo-pockets and inflamed gingiva compro-
advised to follow modified Bass technique for tooth-brushing. She mised oral hygiene perpetuating the inflammation. Investigations
was also prescribed an interdental brush (Thermoseal Proxa Brush including blood investigation, radiographic investigations did not
- NS, IPCA) for cleaning the interdental areas. reveal any significant findings.

The patient was kept under recall for 12 months for monitor- Treatment plan comprised of scaling and root planing and oral
ing the oral hygiene efficiency and to note any signs of recurrence. hygiene instructions. She was advised to use soft bristle tooth-
The self-cleansable contours of the gingiva aided in maintenance of brush and brush her tooth using modified-bass technique of
periodontal health and achieving excellent plaque control. toothbrushing. 0.12% Chlorhexidine mouthwash was prescribed
for plaque control as it was difficult to maintain oral hygiene. After
The patient was followed up for 1 year during which good oral
1 month, inflammation was reduced but enlarged tissue persisted.
hygiene and no recurrence of enlargement was noted. The patient
would no longer cover her mouth and displayed improved confi-
External bevel Gingivectomy procedure was performed to ex-
dence while talking or smiling (Figure 1 and 2).
cise the excess tissue and maintain contours. 2 weeks after gingi-
Case II vectomy, good healing was noted and patient could maintain oral
hygiene. She was referred to Orthodontics Department for further
A 30 year old female, who runs a beauty parlour, came with a
management. The oral hygiene maintenance was facilitated by im-
complaint of swelling and bleeding from upper and lower anterior
provement in alignment of teeth and correction of gingival con-
gums and mobile lower anterior teeth. She first noticed bleeding
tours (Figure 4).
from gums 9 months back while toothbrushing. The gums became
swollen and reddened and gradually increased in size to present
size along with spontaneous bleeding. There were no relevant med-
ical, dental or family history. The blood parameters were normal.

Citation: Deshpande Abhinav., et al. “The Problem of Excess: A Case Series on Gingival Enlargement”. Acta Scientific Dental Sciences 2.9 (2018): 92-98.
The Problem of Excess: A Case Series on Gingival Enlargement

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Figure 1A: Gingival Enlargement involving interdental papilla and marginal gingiva. Stillman’s clefts between enlarged tissue
in maxillary arch.
Figure 1B: 4 weeks post Scaling and root planing.
Figure 1C: Splinting of mandibular anteriors using Ribbond splint material.

Figure 2A: Undisplaced flap procedure. Internal bevel gingivectomy incision.

Figure 2B: Full thickness mucoperiosteal flap elevation and thorough debridement of maxillary arch.
Figure 2C: Suturing of maxillary flaps with simple interrupted suture using 3-0 mersilk suture.
Figure 2D: Internal bevel gingivectomy and Debridement in mandibular arch.
Figure 2E: Suturing of mandibular flaps with simple interrupted suture using 3-0 mersilk suture.
Figure 2F: 1 year post-op. Note the stable periodontal health and well maintained oral hygiene.

Citation: Deshpande Abhinav., et al. “The Problem of Excess: A Case Series on Gingival Enlargement”. Acta Scientific Dental Sciences 2.9 (2018): 92-98.
The Problem of Excess: A Case Series on Gingival Enlargement

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Figure 3A: Diffuse gingival enlargement with unilateral biting habit.

Figure 3B: One week post Scaling and Root Planing.
Figure 3C: Splinting of mandibular anteriors using Ribbond splint material.
Figure 3D: 1 year post scaling. Note the stable dentition and well maintained oral hygiene of the patient. Com
plete resolution of inflammation.

Figure 4A: Diffuse fibrous gingival enlargement covering almost entire crown.
Figure 4B: External Bevel incision using No.15 blade. Gingivectomy performed to excise the enlarged tissue
Figure 4C: Maxillary arch gingivectomy.
Figure 4D: Mandibular arch gingivectomy.
Figure 4E: 1 month Post op.
Figure 4F: Orthodontic alignment of teeth.

Citation: Deshpande Abhinav., et al. “The Problem of Excess: A Case Series on Gingival Enlargement”. Acta Scientific Dental Sciences 2.9 (2018): 92-98.
The Problem of Excess: A Case Series on Gingival Enlargement

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Discussion When chronic inflammatory gingival enlargements include a

significant fibrotic component which does not resolve completely
Gingival overgrowth varies from mild enlargement involving an
after initial periodontal therapy or does not meet the aesthetic and
isolated interdental papilla to segmental or uniform and marked
functional demands of the patient, surgical removal is the treat-
enlargement affecting one or both the jaws having diverse etio-
ment of choice. The most widely employed surgical approaches
pathogenesis [4]. In the initial stages, gingival enlargement appears
for the treatment of gingival enlargements is gingivectomy or the
as a localized nodular enlargement of the interdental papilla (hori-
modified flap technique [1].
zontal growth) and with further progression extends to the dental
crown (vertical growth). In severe cases, the enlarged gingival tis- Patient susceptibility to gingival enlargement is variable and
sue may cover a large portion of the clinical crown [5]. seems to be affected by the degree of gingival inflammation pres-
ent. The exact mechanism of this response is not known.
In initial stages, the increased susceptibility of the interdental
papilla to nodular enlargement compared with marginal gingiva or Gingival connective tissue metabolism is largely controlled by
other parts of the gingiva can be explained by differences in the chemokines and cytokines secreted by inflammatory cells such as
molecular composition of different parts [6]. The cells in the inter- macrophages and lymphocytes and, to a lesser degree, by fibro-
dental papilla are in an activated state and/or inherently display a blasts [12-15] Cytokines regulate a wide range of essential cellular
specific phenotype similar to wound healing. processes such as fibroblast growth, non-collagenous matrix syn-
thesis, and proliferation of ECM proteins in gingival connective tis-
Gingival enlargements are commonly associated with long- sues [16,17]. These processes are relevant to the molecular mech-
standing bacterial plaque accumulation. Oral inflammatory hyper- anism of gingival enlargement [18]. Several studies highlighted
plastic lesions represent an over-exuberant reparative response of that elevated levels of various cytokines including tumor-nec-
tissue to injury [7]. Calculus, overhanging margin of restorations, rotizing factor-a (TNF-a), interleukin- 1b (IL-1b), transforming
foreign bodies, margin of caries, sharp spicules of bone and overex- growth factor-b (TGF-b), connective tissue growth factor (CTGF),
tended borders of appliances are the possible sources of traumatic and platelet-derived growth factor (PDGF) might contribute to the
irritants [8]. These irritants stimulate the formation of granulation pathogenesis of gingival enlargement [19,20].
tissue that consists of proliferating endothelial cells, chronic in-
flammatory cells and few fibroblasts [9]. Hormonal changes during McGaw and colleagues [21] in ultrastructure stereologic stud-
menstruation may also be one of the causes of exuberant prolifera- ies stated that plaque-associated gingival inflammation increases
tion of the gingiva [10]. In present cases, local irritants (plaque and fibroblast synthetic activity. Enlargements represent disorders
calculi) may be considered as primary etiologic factor. of the fibrous connective tissue layer of the oral mucosa, which
proliferates due to continuous stimulation and chronic irritation
Management of such inflammatory enlargements involve re- [22]. These lesions are hyperplastic in nature, not neoplastic [23].
moval of irritants and maintenance of oral hygiene by the patient. Enlargement may result due to increase in number of gingival fi-
As the recurring insult is eliminated, inflammation subsides, vas- broblasts [24] or slower than normal growth. There appears to be
cularity is reduced and the lesion shrinks markedly. The decrease increased collagen synthesis rather than decreased levels of col-
in the size of the lesion is directly proportional to the amount of lagenase activity responsible for enlargement [25].
inflammation present. If the lesion is composed mostly of fibrous
As a preventive measure, chlorhexidine 0.12 once a day has
tissue, there is little shrinkage, but if considerable granulation tis-
been recommended for patients at risk for gingivitis [26]. Occlusal
sue and inflammation exist, there is marked shrinkage [2]. Regular
trauma and dental mobility cause the aggravation of periodontal
professional oral prophylaxis and good patient compliance are re-
lesions. The therapy by means of occlusal adjustment and splint-
quired in the management of such cases.
ing improves the prognosis of teeth affected by periodontal dis-
ease [27].
Non-surgical periodontal therapy, without systemic or local ad-
junct antimicrobial therapy, results in a significant improvement in Histologically, inflammatory fibrous hyperplasia is made up of
periodontal parameters viz. Bleeding on Probing (BOP), Probing a mass of hyperplastic connective tissue with dilated blood ves-
Depth (PD). The circulating levels of inflammatory markers (viz. sels, usually with chronic inflammatory cells such as lymphocytes
C-Reactive Protein, fibrinogen, and WBC counts) are significantly and plasma cells. Fibrous hyperplasia may present with a solid
reduced following mechanical therapy [11]. connective tissue with minimum to no inflammatory cells. The
surface epithelium ranges from normal to acanthotic, ulcerated,
keratotic or a combination of two or more of these features [28].

Citation: Deshpande Abhinav., et al. “The Problem of Excess: A Case Series on Gingival Enlargement”. Acta Scientific Dental Sciences 2.9 (2018): 92-98.
The Problem of Excess: A Case Series on Gingival Enlargement

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Conflict of Interest
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Citation: Deshpande Abhinav., et al. “The Problem of Excess: A Case Series on Gingival Enlargement”. Acta Scientific Dental Sciences 2.9 (2018): 92-98.